Telemedicine demonstrates its utility across the spectrum of urologic care

Aaron Spitz, MD

In this interview, Aaron Spitz, MD, shares highlights from the 2023 American Urological Association (AUA) Quality Improvement Summit regarding telemedicine. He also discusses his own use of telemedicine as well as barriers to its use. Spitz is a urologist with Orange County Urology Associates, Inc in Laguna Hills, California.

At the AUA Quality Improvement Summit, you participated in the session “How to effectively incorporate telehealth into your practice.” Could you summarize some takeaways from this panel discussion?

With regards to [the discussion] "How to effectively incorporate telehealth into your practice," we had a nice representation from private practice such as myself, rural private practice, rural academic practice, and pediatric academic practice, and so we were able to see a wide spectrum of use cases for telemedicine across a wide population of patient types, not only pediatric to adult, not only oncology to sexual medicine and infertility, but also rural to suburban to urban. The takeaway was that telemedicine is very adaptable across the spectrum of patient types and patient demographics. It really has demonstrated itself to be a tool that can be used in a variety of ways, according to the discretion and ingenuity of the urologist. Also, there are limits to what this tool can do, which is true with any tool. There is no universal tool that does all things. This was highlighted effectively by Dr. Julia Finkelstein, whose academic pediatric urologic practice was able to take data that they obtained from telehealth encounters, analyze it, and understand that in cases where an exam of the external genitals; that is, the penis and the scrotum, of the pediatric patient was required, the mismatch between initial and final diagnosis between telehealth encounter and in-office encounter was sufficiently high to where they instituted a quality protocol to ensure that patients with those primary presenting complaints involving the external genitals did in fact have an in-office consultation. But they found that they were able to effectively evaluate and treat many pediatric patients with telemedicine encounters as the primary means of the evaluation. As a negative example, it was instructive to show us that, yes, we must be aware of where the limits in telehealth lie, and with good analysis of good data, we can identify those areas and ensure that we are providing quality care with this tool and working around the limits effectively. But the inverse is also true in that a surprising amount of diagnoses, both in the pediatric and in the adult populations, could in fact be effectively managed with telehealth encounters. At the end of the day, it's not all or none. Another important lesson was that we can combine in-office and telehealth evaluation to provide a complementary and complete evaluation and treatment of our patients, providing the convenience and access when possible through telemedicine, but also giving the complete hands-on physical examination when needed to the same patient.

How are you currently using telemedicine in your practice?

I employ telemedicine in my practice for a suburban population. This is a population that doesn't require telemedical access due to geographic remoteness, or due to barriers to access that might be socioeconomic. It's a fairly affluent suburban population that I care for. However, it does provide my patients a high degree of convenience, and I would contend it does save our community cost. By that, I mean that many of the patients that I'm caring for as a male infertility and sexual medicine specialist are still in the age group that is employed, and many of these people are employed at high managerial or supervisory positions. Many people depend on them for their employment as well, and therefore, our community and its economic status are impacted when patients such as mine are taken out of the loop for medical care. Telehealth allows these highly functioning, hardworking patients to interrupt their workflow for 15 to 20 minutes, instead of 2 to 3 hours, as is often the case when a patient has to come in for an in-office visit, deal with travel there and back as well as the frequent delays that are encountered in the doctor's office. I think that my making telemedicine accessible to a population that doesn't require it from a geographic position but certainly benefits from it from a convenience standpoint, makes a real difference in the overall cost burden of health care in my community.

What are your own biggest challenges and barriers in utilizing telemedicine at the moment?

For me, the biggest barrier to utilizing telemedicine is one that is evaporating, I would say, month to month, and that is just the technical robustness of the telemedical connection. More and more of my patients have faster and faster broadband, and so the connectivity gets better and better. In the earlier days of implementing telemedicine in my practice, I faced much greater frustration with connections that would break down and encounters that would have to then be shifted to some other means; typically telephone landline or cell phone, and suffering through spotty connections, doing your best to to hear and see your patients added another level of fatigue and stress to an already rigorous job. We urologists do have a rigorous job with our patient encounters and deciphering and understanding and evaluating and treating our patients, even when we have perfectly pure fidelity, which is what we have in an in-office encounter. That loss of fidelity of the information coming from the patient to the provider through the telemedical interface really is one of the big challenges that is getting better and better, and I'm certainly seeing that in my practice. Another challenge is the technical savvy of the patient and their ability to access the platform. The platform may work well, the broadband connectivity may be just fine, but the patient on the other end may have trouble understanding how to access it. I am seeing this also diminish month to month; our most senior patients have become more and more comfortable and savvy with using electronic communication because they do it with their family members; they do it with their grandchildren. And so the telemedicine applications are much less foreign to even our oldest patients. Those would be 2 of the bigger barriers that I face but that are getting better. A barrier that I don't face now but I am greatly concerned about as looming as the potential biggest barrier is payment parity. Under the public health emergency, CMS granted payment parity for telehealth encounters and also granted payment for telephone-only encounters, which enabled the patients who didn't have broadband access to still get access to telehealth. Once the public health emergency ended, there was a time at which point payment parity and telephone-only reimbursement would end, which is the end of 2024, unless there is legislation or administrative action to allow the persistence of payment parity and reimbursement for telephone only. I have my eye on that time horizon, because if payment parity does not persist, then it will not be tenable to continue to offer telemedicine to my patients. Certainly, I would not be alone in this dilemma. The cost of running a practice has increased significantly in the past couple of years, and any further decline in revenues, without relief from the increase in cost, would make telemedicine untenable if there is not payment parity for it. And so that, I think, is our biggest obstacle. I think if telemedicine continues to be reimbursed, but at a decreased level, it will wither on the vine. There will always be patients who need it, and there will always be doctors who provide it for those patients who really need it. But the broader adoption that we've seen across urology and across medicine in general would certainly contract, and we would see telemedicine, I believe, wither to a much less meaningful part of health care in this country.

Is there anything you would like to add?

I would say that telemedicine really is a tool. It is best used by the urologist according to their judgment. The concern about fraud and abuse around the use of telemedicine, and the idea that guardrails should be erected around telemedicine to prevent fraud and abuse and to protect patients from improper care has been demonstrated to be an invalid fear, an invalid concern. One of the things we learned from the summit was that a whole variety of diagnoses can be evaluated and managed with high quality and that when fraud and abuse has been examined with internal audits by the Office of the Inspector General, there was only a 0.2% incidence of fraud that could be identified. And so telemedicine is demonstrating itself to be able to provide quality care without a risk of significant fraud and abuse and without the need for excessive guardrails and regulations on how it is being practiced.